桡骨远端骨折合并同侧肘关节损伤的手术治疗体会
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摘要
目的探讨桡骨远端骨折合并同侧肘关节周围骨折或脱位的治疗方法,提高临床治疗效果。方法回顾性分析本院自2012年1月至2016年10月收治的桡骨远端骨折合并同侧肘关节脱位或骨折病例22例。22例桡骨远端骨折中13例伴尺骨茎突骨折,3例伴尺骨远端骨折,2例伴舟状骨骨折。22例肘关节周围损伤中5例为尺桡骨近端骨折,3例为肱骨远端骨折,14例发生肘关节后脱位。结果所有患者均获得随访,术后平均随访时间为13.6个月(11～26个月),所有骨折均愈合,未发生感染。Cooney腕关节评分平均为92.5分(55～100分),其中优13例、良7例、中1例、差1例。Mayo肘关节功能评分平均为87.5分(50～100分),其中优10例、良8例、中3例,差1例。其中1例就诊时已出现骨筋膜室综合征,尺神经、正中神经、桡神经均损伤,肌肉部分坏死切除,功能恢复较差。结论桡骨远端骨折合并同侧肘关节损伤多为高能量损伤,早期积极而恰当的处理能为患者二次手术提供良好的条件,结合积极的康复锻炼,能取得良好的治疗效果。
Background Distal radius fracture combined with ipsilateral elbow fracture or dislocation is rarely seen in clinical practice, and it is often accompanied by highenergy injuries. In recent years, with the increase of accident and high-energy injury, its incidence has the tendency of rise up. Due to heavy injury and rapid disease progression, active and early treatment become particularly critical. If the injury is improperly handled at the early stage, the limitation of soft tissue condition will affect the treatment of fractures and related operations. Osteofascial compartment syndrome may occur in severe cases, leading to irreversible damage. Consequently, the function of elbow and wrist joints would be severely limited, which will affect patients' life quality. Methods Ⅰ. General information: In this study, 22 cases of distal radius fractures combined with ipsilateral elbow fractures or dislocation treated in our hospital from January 2012 to October 2016 were retrospectively analyzed, including 14 males and 8 females. Their ages ranged from 19 to 65 years old, and the mean age was 43.7 years old. Ten cases have the left side affected, and 12 cases have the right side affected. The causes of injury included traffic accident for 12 cases, high falling injurie for 7 cases and fall damage for 3 cases. five cases were combined with head injury, and six cases were combined with chest trauma. According to GustiloAnderson classification, 1 case of type 2 open distal radius fracture was treated with first-stage debridement and sutured in emergency department. Among all patients, 13 cases were combined with ulnar styloid fractures; 3 cases were combined with distal ulna fractures; 2 cases were combined with scaphoid fractures. Out of the 5 cases of open elbow fractures, there were 3 cases of type 1 and 2 cases of type 2 based on Gustilo-Anderson classification. Four cases were fixed with plaster after debridement and suture at the first stage, and one case was temporarily immobilized with external fixator. Of the 22 patients, there were 5 cases of proximal ulna and radius fractures, 3 cases of distal humeral fractures and 14 cases of posterior elbow joint dislocation. Among the 14 cases: 11 cases were combined with radial head fractures; 10 cases were combined with ulna coracoid process fractures; 12 cases were combined with lateral collateral ligament injury; 9 cases were combined with medial collateral ligament injury. Ⅱ. Treatment methods:(1) Early management: The elbow dislocation and obvious deformity fractures were reduced and immobilized with plaster fixation over elbow and wrist joints in all patients after admission. For open fractures in proper condition, debridement and suture could be performed at the first stage. For comminuted periarticular fractures, external fixator could be adopted for temporary fixation, and fasciotomy should be performed in the patients with severe swelling to reduce tension. After admission, the affected limb was raised with ice compress, and 125 ml of 20% mannitol was applied intravenously 2 times per day.(2) Secondary surgery: The surgery was usually performed after the swelling was subsided(5-14 days). After general anesthesia or brachial plexus block, the elbow joint was re-checked for dislocation or remarkable deformity. Due to the less demanding for body position, open reduction and internal fixation of distal radius fracture was firstly performed. For combined distal ulna fracture, the treatment of periarticular fracture was considered after reduction and fixation. The prearticular fracture of wrist: Henry approach was adopted at the distal forearm for fixation with volar T-shaped anatomical locking plate or reconstruction locking compression plate; the distal ulna fracture could be fixed with micro locking plate or reconstruction locking plate; the ulnar styloid base fracture was fixed with 1.0 mm Kirschner wire; the canicular fracture was treated with open reduction and Herbert screw fixation. The prearticular fracture of elbow: open reduction and internal plate fixation were applied for radioulnar fracture or distal humeral fracture; Kocher approach was adopted for fixation of simple radial head fracture or combined collateral ligament injury; Herbert screw or micro plate was used for fixation of radial head fracture in the safe area, and radial head replacement could be used in severe cases. For patient with elbow varus instability, the collateral ligament was repaired with suture anchor; For patient with simple ulnar coronoid process fracture or combined medial collateral ligament injury, the fracture was fixed via interior incision. For patient with elbow valgus instability, the medial collateral ligament was repaired with suture anchor.(3) Postoperative treatment: Antibiotics was used within 24 hours to prevent infection, and 125 ml of 20% mannitol was used intravenously 2 times per day. The affected extremity was elevated and treated with ice compress. The drainage tube was removed within 48 hours. The stability of elbow joint was evaluated intraoperatively. For patient with unstable elbow joint, the forearm was immobilized in postoperative conventional cast of 90° for 1 week to maintain the central reduction of elbow and to protect the repaired medial and lateral collateral ligaments.Elbow flexion and extension exercises were conducted under the protection of adjustable brace 1 week later, and forearm rotation exercise was allowed without brace 1 month later. Alternatively, the elbow joint was immobilized with external fixator, and functional exercise was initiated as the postoperative soft tissue condition was allowed. After operation, 25 mg of indomethacin was taken 3 times per day for 3 weeks to prevent the occurrence of heterotopic ossification around elbow joint. Results All patients were followed up for an average of 13.6 months(11-26 months). X-ray examination was performed in the 1 st, 2 nd, 3 rd, 6 th and 12 th months after the operation respectively. At the end of follow-up, Mayo elbow performance score and Cooney wrist score were used for comprehensive assessment. All the fractures healed without refracture, dislocation or infection. There were 6 cases of heterotopic ossification and 11 cases of elbow joint limitation in various degrees. One patient had osteofascial compartment syndrome at the time of treatment and received incision decompression and removal of necrotic muscle and soft tissue. Internal fixation was performed after the healing of wound. Thus, the functions of elbow and wrist were severely limited. The mean Cooney wrist score was 92.5 points(55-100 points), including 13 excellent cases, 7 good cases, 1 moderate case and 1 poor case. The good and excellent rate was 90.9%. The mean Mayo elbow score was 87.5 points(50-100 points), including 10 excellent cases, 8 good cases, 3 moderate case and 1 poor case. Conclusions As high-energy injury, distal radial fracture combined with ipsilateral elbow injury has rapid progression. Timely and appropriate emergency treatment can provide a good condition of soft tissue for secondary operation. Extra attention should be paid to avoid the occurrence of osteofascial compartment syndrome, and good therapeutic effect can be obtained with active rehabilitation exercise.
Background Distal radius fracture combined with ipsilateral elbow fracture or dislocation is rarely seen in clinical practice, and it is often accompanied by highenergy injuries. In recent years, with the increase of accident and high-energy injury, its incidence has the tendency of rise up. Due to heavy injury and rapid disease progression, active and early treatment become particularly critical. If the injury is improperly handled at the early stage, the limitation of soft tissue condition will affect the treatment of fractures and related operations. Osteofascial compartment syndrome may occur in severe cases, leading to irreversible damage. Consequently, the function of elbow and wrist joints would be severely limited, which will affect patients' life quality. Methods Ⅰ. General information: In this study, 22 cases of distal radius fractures combined with ipsilateral elbow fractures or dislocation treated in our hospital from January 2012 to October 2016 were retrospectively analyzed, including 14 males and 8 females. Their ages ranged from 19 to 65 years old, and the mean age was 43.7 years old. Ten cases have the left side affected, and 12 cases have the right side affected. The causes of injury included traffic accident for 12 cases, high falling injurie for 7 cases and fall damage for 3 cases. five cases were combined with head injury, and six cases were combined with chest trauma. According to GustiloAnderson classification, 1 case of type 2 open distal radius fracture was treated with first-stage debridement and sutured in emergency department. Among all patients, 13 cases were combined with ulnar styloid fractures; 3 cases were combined with distal ulna fractures; 2 cases were combined with scaphoid fractures. Out of the 5 cases of open elbow fractures, there were 3 cases of type 1 and 2 cases of type 2 based on Gustilo-Anderson classification. Four cases were fixed with plaster after debridement and suture at the first stage, and one case was temporarily immobilized with external fixator. Of the 22 patients, there were 5 cases of proximal ulna and radius fractures, 3 cases of distal humeral fractures and 14 cases of posterior elbow joint dislocation. Among the 14 cases: 11 cases were combined with radial head fractures; 10 cases were combined with ulna coracoid process fractures; 12 cases were combined with lateral collateral ligament injury; 9 cases were combined with medial collateral ligament injury. Ⅱ. Treatment methods:(1) Early management: The elbow dislocation and obvious deformity fractures were reduced and immobilized with plaster fixation over elbow and wrist joints in all patients after admission. For open fractures in proper condition, debridement and suture could be performed at the first stage. For comminuted periarticular fractures, external fixator could be adopted for temporary fixation, and fasciotomy should be performed in the patients with severe swelling to reduce tension. After admission, the affected limb was raised with ice compress, and 125 ml of 20% mannitol was applied intravenously 2 times per day.(2) Secondary surgery: The surgery was usually performed after the swelling was subsided(5-14 days). After general anesthesia or brachial plexus block, the elbow joint was re-checked for dislocation or remarkable deformity. Due to the less demanding for body position, open reduction and internal fixation of distal radius fracture was firstly performed. For combined distal ulna fracture, the treatment of periarticular fracture was considered after reduction and fixation. The prearticular fracture of wrist: Henry approach was adopted at the distal forearm for fixation with volar T-shaped anatomical locking plate or reconstruction locking compression plate; the distal ulna fracture could be fixed with micro locking plate or reconstruction locking plate; the ulnar styloid base fracture was fixed with 1.0 mm Kirschner wire; the canicular fracture was treated with open reduction and Herbert screw fixation. The prearticular fracture of elbow: open reduction and internal plate fixation were applied for radioulnar fracture or distal humeral fracture; Kocher approach was adopted for fixation of simple radial head fracture or combined collateral ligament injury; Herbert screw or micro plate was used for fixation of radial head fracture in the safe area, and radial head replacement could be used in severe cases. For patient with elbow varus instability, the collateral ligament was repaired with suture anchor; For patient with simple ulnar coronoid process fracture or combined medial collateral ligament injury, the fracture was fixed via interior incision. For patient with elbow valgus instability, the medial collateral ligament was repaired with suture anchor.(3) Postoperative treatment: Antibiotics was used within 24 hours to prevent infection, and 125 ml of 20% mannitol was used intravenously 2 times per day. The affected extremity was elevated and treated with ice compress. The drainage tube was removed within 48 hours. The stability of elbow joint was evaluated intraoperatively. For patient with unstable elbow joint, the forearm was immobilized in postoperative conventional cast of 90° for 1 week to maintain the central reduction of elbow and to protect the repaired medial and lateral collateral ligaments.Elbow flexion and extension exercises were conducted under the protection of adjustable brace 1 week later, and forearm rotation exercise was allowed without brace 1 month later. Alternatively, the elbow joint was immobilized with external fixator, and functional exercise was initiated as the postoperative soft tissue condition was allowed. After operation, 25 mg of indomethacin was taken 3 times per day for 3 weeks to prevent the occurrence of heterotopic ossification around elbow joint. Results All patients were followed up for an average of 13.6 months(11-26 months). X-ray examination was performed in the 1 st, 2 nd, 3 rd, 6 th and 12 th months after the operation respectively. At the end of follow-up, Mayo elbow performance score and Cooney wrist score were used for comprehensive assessment. All the fractures healed without refracture, dislocation or infection. There were 6 cases of heterotopic ossification and 11 cases of elbow joint limitation in various degrees. One patient had osteofascial compartment syndrome at the time of treatment and received incision decompression and removal of necrotic muscle and soft tissue. Internal fixation was performed after the healing of wound. Thus, the functions of elbow and wrist were severely limited. The mean Cooney wrist score was 92.5 points(55-100 points), including 13 excellent cases, 7 good cases, 1 moderate case and 1 poor case. The good and excellent rate was 90.9%. The mean Mayo elbow score was 87.5 points(50-100 points), including 10 excellent cases, 8 good cases, 3 moderate case and 1 poor case. Conclusions As high-energy injury, distal radial fracture combined with ipsilateral elbow injury has rapid progression. Timely and appropriate emergency treatment can provide a good condition of soft tissue for secondary operation. Extra attention should be paid to avoid the occurrence of osteofascial compartment syndrome, and good therapeutic effect can be obtained with active rehabilitation exercise.
引文
[1]Beach PM,Hewson JS.Elbow dislocation with comminuted fracture of the proximal radial shaft.Thoughts on the mechanism[J].Am J Surg,1966,112(6):941-942.
[2]Ring D,Waters PM,Hotchkiss RN,et al.Pediatric floating elbow[J].J Pediatr Orthop,2001,21(4):456-459.
[3]Cengiz?,Polat G,Karademir G,et al.Ipsilateral olecranon and distal radius fracture:A case report[J].Int J Surg Case Rep,2015,6:194-197.
[4]Shiboi R,Kobayashi M,Watanabe Y,et al.Elbow dislocation combined with ipsilateral Galeazzi fracture[J].J Orthop Sci,2005,10(5):540-542.
[5]Lange RH,Foster RJ.Skeletal management of humeral shaft fractures associated with forearm fractures[J].Clin Orthop Relat Res,1985(195):173-177.
[6]Yokoyama K,Itoman M,Kobayashi A,et al.Functional outcomes of"floating elbow"injuries in adult patients[J].J Orthop Trauma,1998,12(4):284-290.
[7]Hwang RW,De Witte PB,Ring D.Compartment syndrome associated with distal radial fracture and ipsilateral elbow injury[J].J Bone Joint Surg Am,2009,91(3):642-645.
[8]吴加东,卞化,沈孝天,等.肘关节"恐怖三联征"合并肱骨远端骨折的手术治疗[J/CD].中华肩肘外科电子杂志,2017,5(3):194-198.
[9]张弛,仲飙,罗从风,等.外侧入路联合前内治疗肘关节“恐怖三征”的手术效[J].中华骨科杂志,2015,35(4):320-327.
[10]Rosell P,Clasper J.Roles of the medial collateral ligament and the coronoid in elbow stability[J].J Bone Joint Surg Am,2003,85A(3):568.
[11]Jeong WK,Oh JK,Hwang JH,et al.Results of terrible triads in the elbow:the advantage of primary restoration of medial structure[J].J Orthop Sci,2010,15(5):612-619.
[12]仲飙,张弛,罗从风,等.肘关节“恐怖三联征”中内侧副韧带及合并损伤的治疗策略[J].中华骨科杂志,2013,33(5):534-540.
[13]Chemama B,Bonnevialle N,Peter O,et al.Terrible triad injury of the elbow:how to improve outcomes?[J].Orthop Traumatol Surg Res,2010,96(2):147-154.
[14]Schneeberger AG,Sadowski MM,Jacob HA.Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow[J].J Bone Joint Surg Am,2004,86A(5):975-982.
[15]Dowdy PA,Bain GI,King GJ,et al.The midline posterior elbow incision.An anatomical appraisal[J].J Bone Joint Surg Br,1995,77(5):696-699.
[2]Ring D,Waters PM,Hotchkiss RN,et al.Pediatric floating elbow[J].J Pediatr Orthop,2001,21(4):456-459.
[3]Cengiz?,Polat G,Karademir G,et al.Ipsilateral olecranon and distal radius fracture:A case report[J].Int J Surg Case Rep,2015,6:194-197.
[4]Shiboi R,Kobayashi M,Watanabe Y,et al.Elbow dislocation combined with ipsilateral Galeazzi fracture[J].J Orthop Sci,2005,10(5):540-542.
[5]Lange RH,Foster RJ.Skeletal management of humeral shaft fractures associated with forearm fractures[J].Clin Orthop Relat Res,1985(195):173-177.
[6]Yokoyama K,Itoman M,Kobayashi A,et al.Functional outcomes of"floating elbow"injuries in adult patients[J].J Orthop Trauma,1998,12(4):284-290.
[7]Hwang RW,De Witte PB,Ring D.Compartment syndrome associated with distal radial fracture and ipsilateral elbow injury[J].J Bone Joint Surg Am,2009,91(3):642-645.
[8]吴加东,卞化,沈孝天,等.肘关节"恐怖三联征"合并肱骨远端骨折的手术治疗[J/CD].中华肩肘外科电子杂志,2017,5(3):194-198.
[9]张弛,仲飙,罗从风,等.外侧入路联合前内治疗肘关节“恐怖三征”的手术效[J].中华骨科杂志,2015,35(4):320-327.
[10]Rosell P,Clasper J.Roles of the medial collateral ligament and the coronoid in elbow stability[J].J Bone Joint Surg Am,2003,85A(3):568.
[11]Jeong WK,Oh JK,Hwang JH,et al.Results of terrible triads in the elbow:the advantage of primary restoration of medial structure[J].J Orthop Sci,2010,15(5):612-619.
[12]仲飙,张弛,罗从风,等.肘关节“恐怖三联征”中内侧副韧带及合并损伤的治疗策略[J].中华骨科杂志,2013,33(5):534-540.
[13]Chemama B,Bonnevialle N,Peter O,et al.Terrible triad injury of the elbow:how to improve outcomes?[J].Orthop Traumatol Surg Res,2010,96(2):147-154.
[14]Schneeberger AG,Sadowski MM,Jacob HA.Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow[J].J Bone Joint Surg Am,2004,86A(5):975-982.
[15]Dowdy PA,Bain GI,King GJ,et al.The midline posterior elbow incision.An anatomical appraisal[J].J Bone Joint Surg Br,1995,77(5):696-699.